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662 > AKI > Flashcards

AKI Flashcards

1
Q

Drug dosing in AKI

A
  • Decision to dose adjust medications should be a clinical decision based on CrCl, UO, and suggested dosing guidelines
  • Calculate CrCl and review UO daily
  • Dose reduce based on suggested guidelines
  • Consider serum drug concentrations
  • Dose adjust back up when renal function recovers
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2
Q

AKI pt evaluation steps

A
  1. Discontinue nephrotoxic medications
  2. Identify cause of AKI
  3. Treat AKI
  4. Renally dose adjust medications
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3
Q

Post renal AKI diagnosis

A
  • Renal imaging
  • UA: Hematuria, crystals
  • BUN:SCr <15:1
  • FeNa > 1%
  • No daily change in SCr
  • Anuria
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4
Q

Be able to identify and treat different types of AKI

Know how to calculate a CrCl and UO

Be familiar with prevention strategies

Know common medication nephrotoxins

Dose adjust medications in AKI

A
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5
Q

Urinary Analysis

A
  • Hydration
    • Color
      • Dark yello=dehydrated
    • Specific gravity
    • >1.020 = dehydration
  • Infection
    • WBC
      • >50= infection
    • Leucocyte esterase
      • Production of neutrophils
      • 1+,2+, 3+ = infection
    • Nitrites
      • made by bacteria
      • Positive= infection
  • Kidney Function
    • Protein, 1+,2+,3+ = intrinsic renal failure
    • RBC, Positive = Traumatic catheterization, tumor, nephrolithiasis
  • Casts
    • Different types (hyaline, granular)
    • Positive = intrinsic renal failure
  • Crystals
    • Different types (uric acid, calcium oxalate)
    • Positive = tumor lysis syndrome or nephrolithiasis
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6
Q

Types of Acute Kidney Injury

A

Prerenal

Intrinsic

Postrenal

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7
Q

Prerenal AKI

A
  • Occurs prior to the kidney
  • Reduction in blood volume
  • Reduction in bloodflow to the kidney
    • Hypotension
    • Sepsis
    • Heart or liver failure
    • Bleeding
    • Renal thrombosis
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8
Q

AKI definition

Decline in?

Increase?

Increase?

A
  • Abrupt reduction in kidney function
    • Decline in urine output
    • Increase SCr
    • Increase BUN
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9
Q

Post renal failure tx

A
  • Remove obstruction
    • Nephrolithiasis- lithotripsy
    • Tumore= Surgery
    • Stricture = urinary stent
    • BPH = doxazosin, tamulosin, finasteride
  • Hydronephrosis
    • Nephrostomy tube
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10
Q

Prerenal Failure Tx

A
  • Restore blood volume
    • IV fluids- aggresive rehydration with normal saline or balance solution
    • Discontinue diuretics
  • Restore blood flow
    • Blood - indicated in bleeding situations
    • Treat the underlying cause conditions (heart failure, sepsis)
  • Discontinue and limit nephrotoxins
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11
Q

Types of intrinsic AKI

A

ATN and AIN

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12
Q

CRRT

A
  • Indicated when blood pressure too low to tolerate HD
  • Continual removal of fluids and solutes so more resembles actual kidney function
  • Differ in way the solute is removed
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13
Q

Diagnosing prerenal AKI

A
  • Pt hx, N/V, diarrhea
  • Dry mucous membranes, decrease jugular venous distension
  • UA: Dark yello, high specific gravity
  • BUN:SCr > 20:1
  • Urinary Na < 10
  • FeNa < 1%
  • Oliguria
  • Rapid change in SCr with tx
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14
Q

AKI symptoms

A
  • Fluid overload
    • SOB
    • Peripheral edema
    • wt gain
  • Urinary Changes
    • Decreased or painful urination
    • Change in color or odor
  • Uremia
    • N/V
    • Itching
    • Fatigue
    • Confusion
  • Situation
    • Flank pain
    • HA
    • Arthralgia
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15
Q

AKI complications

A
  • Fluid overload
    • Pulmonary and peripheral edema
    • IV bolus loopd diuretics –> Continuous infusion loop diuretics —> hemodialysis
  • Electrolyte abnormalities
    • Increase K, Phosphorus, magnesium
    • Hyperkalemia most common and concerning
  • Blood glucose irregularities
    • Hyperglycemia common due to impaired glucose homeostasis and metabolic stress
    • Insulin eliminated by the kidneys so may result in hypoglycemia
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16
Q

Drug dosing in AKI

HD

and

CRRT

A
  • Assume little to no UO
  • Drug elimination dependent on filter type, flow rate, amount of time on HD and drug characteristics
    • Molecule size, protein binding, ionized form
  • Dosing different for each medication
    • Bolus dosing daily or 3 times/week after HD

CRRT

  • Dependent on flow rate but usually assume normal renal function with no drug adjustment
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17
Q

ATN -

A

Nephrotoxic meds

  • ACEs
  • ARBs
  • NSAIDs
  • Amnoglycosides
  • Vancomycin
  • Amphotericin B
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18
Q

ATN- Rhabdomyolysis

A

Rhabdomyolysis

  • breakdown of muscle cells releases damaging proteins into systemic circulation
  • Seen by an increase in CPK and myoglobin
  • Myoglobin specifically damages kidneys
  • Serum myoglobin level useful in diagnosis
  • Treat with fluids such as normal saline or sodium bicarbonate
19
Q

Risk factors for AKI

A
  • Male
  • AA
  • Advanced Age
  • CKD
  • DM
  • Heart or Liver Disease
  • Surgery
  • Sepsis
  • Hypotension
  • Volume depletion
    • Diarrhea
    • Vomiting
    • Dehydration
  • Medications
20
Q

AKI monitoring

A
  • Daily wts
  • Fluid intake and UO
  • Daily serum creatinine
  • daily serum electrolytes
  • Vital signs
  • Symptoms (edema)
21
Q

Post Renal AKI

A
  • Occurs after kidney
  • Caused by an obstruction between kidney and urethra
    • Nephrolithiasis
    • Uric acid crystals
    • Tumor
    • Stricture
    • BPH
22
Q

Type of renal replacemen

A

Hemodialysis

Rapid removal of fluids and solute

Performed daily in acute setting or 3 x

common complication hypotension

23
Q

AKI treatment goals

A
  • Restore renal function to baseline
  • Identify the cause
  • Reverse the cause
  • Limit damage
  • treat symptoms
  • Manage complications
24
Q

Modification of Diet in Renal Disease (MDRD)

A
  • Calculate an eGFR
  • Better estimates renal function
  • Utilized to stage renal failure
25
Q

Indications for renal replacement therapy

AEIOU

A
  • Acidosis
  • Electrolytes
  • Intoxication
  • Overload
  • Uremia
26
Q

ATN

A

Contrast Induced Nephropathy

  • Dye causes free radical formation which is directly toxic to the kidneys
  • SCr increase 2-5 days after contrast exposure
  • Prevention is key
    • Normal saline or sodium bicarb infusion
    • N-Acetylcysteine
27
Q

SCr

A
  • Must know pts baseline
  • Trend in SCr more important than acutal level
  • Lag in SCr change by 1-2 days from original insult
  • Use of GFR equations limited as these assume stable renal function
28
Q

Urine Output

A
  • Most acute marker of change in renal function
  • Conern when <0.5 mL/kg/hr
  • Complicated by volume status, diuretic use and obstruction
  • Nomentclature
    • Nonoliguric is > 500 ml/day
    • Oliguric <500 ml/day
    • Anuric <50 mL/day
29
Q

Acute Interstitial Nephritis AIN

A
  • Delayed hypersensitivty rxn
  • Tubular and Interstitial inflammation
  • Symptom triad, Fever, Rash, Urine Eosinophils
  • Medications most common cause
    • beta lactam antibiotics
    • NSAIDs
    • Trimethoprim/ sulfamethoxazole
30
Q

Review

A
  • Normal kidney function markers
  • Definite, detect and classify AKI
  • Types of AKI
    • Diagnosis and tx
    • Prerenal, intrinsic and postrenal
  • Renal replacement therapy
  • Complications of AKI
  • Drug dosing in AKI
  • AKI prevention
31
Q

Fractional Excretion of Sodium

A
  • Reflection of ability of kidney to concentrate urine
  • Not accurate if recent diuretic use
32
Q

AKI Markers and lab testing

A
  • SCr
  • UO
  • Urinary Analysis
  • Urine Electrolytes
  • Renal imaging
33
Q

Urine output criteria

Risk

injury

Failure

Loss ESRD

A
  • UO < 0.5 ml/kg
  • UO < 0.5 ml/kg x 12 hours
  • UO < 0.3 ml/kg x 24 hours or anuria x 12 (oliguria)
  • Persistent ARF = complete loss of renal function > 4 weeks
  • ESRD
34
Q

Kidney Function Markers

Urine Output

Normal Output?

How to calculate?

A
  • Best marker of urine function
  • Normal urine output = 0.7-1 ml/kg/hr
  • To calculate determine amount of urine output and divide by the pts weight and time period
35
Q

Kidney Function Markers

Serum Creatinine

A

SCr < 1

Affected by age, gender, muscle mass, diet and hydration status

Some medications may increase

36
Q

Intrinsic AKI

A
  • Direct damage can be due to the glomerulus or tubules
  • Kidney injury a result of
    • Ischemia
    • Toxins
      • Medications
      • Contrast dye
      • Proteins (myoglobin)
37
Q

AKI classifications

Staging Criteria

Types of Staging systems

A
  • Staging
    • SCr change for baseline
    • GFR change from baseline
    • Urine output over specified time period
  • Systems
    • Risk, Injury Failure, Loss of Function and ESKD (RIFLE)
    • Acute Kidney Injury Network (AKIN)
    • Kidney Disease: Improving global Outcumes (KDIGO)
38
Q

glomerular filtration rate

equation

A

(140-age) x wt (kg)

/

72 x SCr

if female x by 0.85

39
Q

GFR Criteria

Risk

Injury

Failure

Loss

ESRD

A
  • Increased creatinine x 1.5 or GFR decrease > 25%
  • Increased creatinine x 2 or decrease >50%
  • Increased creatinine x 3 or >75% decrease or creatinine > 4 mg per 100 mL
  • Persistent ARF = Complete loss of renal function > 4 wks
  • ESRD
40
Q

Renal imaging

A

Renal ultrasounds

Abdominal CT scan

41
Q

Intrinsic renal failure treatment

A
  • Discontinue offending agent
  • IV-fluids- normal saline or balanced solutions
  • Limit nephrotoxins
42
Q

Normal Renal Function

A WET BED

A
  • A- Acid/base balance
  • W-Water balance
  • Electrolyte balance
  • Toxin Removal
  • Blood pressure control (Renin)
  • Erythropoietin production
  • Vitamin D activation
43
Q

Intrinsic AKI diagnosis

A
  • UA: Protein, granular casts, eosinophils
  • BUN:SCr < 15:1
  • FeNa > 1%
  • Slow change in SCr with tx

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